Medical Tourism Part 2: Low cost, but is the quality high?

Medical Tourism Part 2: Low cost, but high quality?

Depending on who you believe, anywhere from 50,000 to as many as 750,000 Americans are leaving the country each year to receive medical treatment abroad . No one seems to disagree on the fact that the numbers keep going up. Medical tourism is a growing business.

Yet, right now there is no mandated regulatory oversight of the industry. That puts the onus on consumers to learn whether a foreign hospital - including the doctors and staff - are qualified to provide care that is comparable to the US.

In the past few years, several accreditation organizations have been created to develop standards. The most recognized is the Joint Commission International (JCI) which is the international division of the Joint Commission  that reviews and accredits American hospitals. JCI has accredited more than 260 facilities in 34 countries, setting over 350 standards of excellence for international hospitals including patient satisfaction and quality outcomes, medical training of doctors and medical staff, nurse to patient ratios, overall hospital cleanliness, and innovation in medical technology and equipment.

Similarly, Australia and Canada have extended their accreditation programs into the international arena. The Australian Council on Healthcare Standards (ACHS) focuses on four major topics: safe management of blood, infection control, falls prevention, and continuity of care among healthcare providers. Accreditation Canada is a 50-year-old not-for-profit, independent organization accredited by the International Society for Quality in Healthcare (ISQua). It provides international health care organizations in Bermuda, Brazil, Italy, Kuwait and Saudi Arabia with an external peer review process to assess and improve the services they provide to their patients and clients based on standards of excellence.

While these are all international arms of respected national accreditation organizations in the US, Australia, and Canada, the standards and quality criteria of accrediting groups from many other countries are less well defined and often not independent. For example, the Center for Healthcare Planning and Quality (CPQ) based in Dubai regulates its own medical facility.

Increasingly, foreign hospitals are developing affiliations with major US hospitals including Johns Hopkins, Duke, Harvard, the Mayo Clinic, Memorial Sloan-Kettering, Cleveland Clinic, University of Texas, and the University of Pittsburgh. As a consumer, you need to know that just because a foreign hospital claims affiliation with a well-respected name, does not always ensure the same caliber of care.

So how can you determine the differences in standards among hospitals that are accredited through one of these groups or claim affiliation with a well-known US hospital?

To help consumers, there are dozens of medical tourism facilitators acting as liaisons between patients and foreign physicians and hospitals, scheduling surgeries, buying airline tickets, making hotel, local transportation and visa arrangements, handling billing and even setting up sightseeing tours for recovering patients. They may also help arrange follow-up care.

But just as with accreditation, there is no mandated regulatory body and no licensing requirement that qualifies them.

Medical Tourism Association, (MTA) is a nonprofit organization made up of hospitals insurers, and tourist groups interested in expanding the role of international travel for medical care. Although MTA has introduced a facilitator certification program for its members, there is no requirement that applicants have any clinical background. Members pay $2,500 biannually to the MTA and refer patients to only facilities and partners within the MTA network. Even though a particular firm is a member, MTA recommends that consumers get their own references and try to interview former patients.

In 2008, in response to the growth of international travel for medical care, the American Medical Association developed new guidelines on medical tourism. 

Satori World Medical  a company that develops global health networks is one organization that not only follows these guidelines, but, according to CEO Steve Lash, exceeds them. In a phone interview this week Lash explained that unlike most other medical travel facilitators, Satori has a full time Chief Medical Officer on board. Dr. Ron Johnson is a board certified surgeon with 30 years of practice experience who has personally traveled to all 14 hospitals in Satori’s network and actually scrubbed in with the surgeons there. Ona regular basis, he makes site visits to continually evaluate performance. The company also has a Medical Quality Advisory Board composed of physicians and dentists who help him set guidelines, and review performance measures and outcomes. Surgically-trained registered nurses and travel/customer service representatives help patients negotiate the entire process from the first phone call to follow-up, including scheduling a post-operative appointment back in the U.S. before even leaving the country for surgery. Other components include facilitating medical records transfer, communications with the insurer, U.S. physician, international physician and patient, and scheduling all travel arrangements for both the patient and a companion.

In summary:
Even if you have an insurer or are an employee of a company that offers overseas care with a facilitator like Satori that provides door-to-door services, it is still important to do your own homework.

- Begin with the Internet. Check the facilities recommended online. Don’t be impressed just by fancy patient suites or the promise of gourmet food.

- Check for accreditation. See if the hospital is accredited by one of the agencies discussed above such as JCI whose standards are comparable to those in the US. Make sure that the entire facility is accredited and not simply an affiliated lab or clinic.

- Check credentials of the doctor who will be performing your surgery, including how many of your procedure he or she has done and the outcomes.

You might be surprised to learn that many international hospitals do much higher volumes of certain procedures than even academic institutions in the US. Generally the more experience a facility has with specific surgeries, the better the outcomes. For example, Escorts Heart Institute and Research Center in Delhi, India performs nearly  15,000 heart operations each year, and has a reported death rate among patients during surgery of only 0.8 percent which is less than half the equivalent rate in most major US hospitals.

- Ask how the facility handles blood safety and hospital infection rates.

- Talk to the surgeon It is important to speak with the physician who will be doing your procedure directly before you leave the country. That provides a good opportunity to develop a relationship and you can determine how well he or she speaks English. Include these questions:
     - If you are having a procedure such as hip or knee replacement, ask if whatever device will be used       has been FDA approved.
      - How long will my recovery be?
      - Will I have pain and how does the doctor/hospital manage it?
      - Will there be physical therapy involved and is it done onsite or elsewhere?
      - Will the long flight home present any special problems?

- Travel with a companion who will be with you during the entire experience and can act as an advocate

- Check out available resources in terms of language, and food. English should be spoken by most of the staff who will be managing your care – especially doctors and nurses.

- Ask about preventive therapy. Depending on what country you are considering, there may be issues of potential exposure to endemic diseases like malaria. Ask if you require preventive therapy before you travel.

- Arrange follow-up care before you go
Once you return to the US, liability concerns and unfamiliarity with the techniques or devices used overseas may make physicians less than eager to treat complications resulting from your procedure. Schedule a visit with your primary care physician before you leave including, if possible, any specialist involved in your care in the states. Let them know your plans and contact information. Ideally they should provide your medical records electronically to your physicians overseas. At the very least, bring a paper record of your medical history. And be sure to ask what medical records and information you will need to bring home to complete your care.

Finally, before you leave, arrange a phone or e-mail conference between your doctors at home and the doctor who will be caring for you overseas. The best way to ensure continuity of your care is to establish communication before a problem arises.

Bottom line: While there are definitely potential risks associated with getting care overseas, it is also true that many international hospitals deliver high-quality care and customer-focused service that rivals that in the US. Even within the US, quality varies dramatically between hospitals, and evidence-based best medical practices are not consistent.

If the following story told by a South Carolina gastroenterologist to his colleagues is any indication, one potential side effect of the trend towards medical tourism could be an increased impetus to improve service as well as quality in many US hospitals:

“Yesterday, I was doing a screening colonoscopy on a local businessman who was planning his prostate cancer surgery using the robotic DaVinci technique. He had already done his research before the second meeting with his local urological surgeon who diagnosed his problem and staged the cancer. He had narrowed his choice between Johns Hopkins and Bangkok. He was seriously considering having the surgery done outside the US for better outcomes. He is not even planning on using his Blue CrossBlueShield insurance for surgery locally! That is market force in full gear. If this is happening in rural South Carolina, imagine what can happen in New York, California and other big cities if we don't shape up and learn to respect our customers."

For more information about medical tourism including country-specific resources: Read Patients Beyond Borders by Josef Woodman